Beyond social determinants: Fiscal determinants of overdose death in U.S counties, 2017-2020

A large body of research has been dedicated to understanding the relationship between social determinants of health (SDOH) and overdose death across counties in the United States (U.S). However, this literature has so far focused on demographic and socioeconomic characteristics of counties and has largely overlooked the ways in which county fiscal constraints may be associated with responses to the opioid epidemic. To address this gap, this longitudinal study uses data from the U.S Census of Governments to examine the associations between county governments' revenues and expenditures, commonly used measures of SDOH, and overdose deaths in U.S counties from 2017 to 2020. We find that along with SDOH, higher per capita police spending, but not health expenditures, was associated with overdose deaths in U.S counties. Furthermore, we find that the link between police spending and overdose mortality depends on the amount of revenue generated through fines and forfeitures, suggesting it is a particular form of expenditures on policing - those linked to extractive practices- that is associated with overdose. This study heightens understanding on how the strategies counties undertake in generating and utilizing public resources impact overdose outcomes. Future studies should focus on measuring the causal impact of policies that significantly alter local revenue sources and expenditures on overdose deaths at the county level.